National nutrition surveillance programmes in 18 countries in South-East Asia and Western Pacific Regions: a systematic scoping review

Abstract Objective To identify and analyse ongoing nutrition-related surveillance programmes led and/or funded by national authorities in countries in South-East Asian and Western Pacific Regions. Methods We systematically searched for publications in PubMed® and Scopus, manually searched the grey literature and consulted with national health and nutrition officials, with no restrictions on publication type or language. We included low- and middle-income countries in the World Health Organization South-East Asia Region, and the Association of Southeast Asian Nations and China. We analysed the included programmes by adapting the United States Centers for Disease Control and Prevention’s public health surveillance evaluation framework. Findings We identified 82 surveillance programmes in 18 countries that repeatedly collect, analyse and disseminate data on nutrition and/or related indicators. Seventeen countries implemented a national periodic survey that exclusively collects nutrition-outcome indicators, often alongside internationally linked survey programmes. Coverage of different subpopulations and monitoring frequency vary substantially across countries. We found limited integration of food environment and wider food system indicators in these programmes, and no programmes specifically monitor nutrition-sensitive data across the food system. There is also limited nutrition-related surveillance of people living in urban deprived areas. Most surveillance programmes are digitized, use measures to ensure high data quality and report evidence of flexibility; however, many are inconsistently implemented and rely on external agencies’ financial support. Conclusion Efforts to improve the time efficiency, scope and stability of national nutrition surveillance, and integration with other sectoral data, should be encouraged and supported to allow systemic monitoring and evaluation of malnutrition interventions in these countries.


Introduction
2][3] Malnutrition is causing the most diseases and premature deaths in this region, and is associated with social and economic burdens. 3Despite substantial progress in reducing the prevalence of undernutrition, most countries are not meeting the global targets on maternal, infant and young child nutrition indicators for 2025.Moreover, no countries are on track to curb adult and childhood obesity. 4here has been a call for a transformative shift in how we conceptualize, develop and evaluate nutrition interventions.The goal is to synergistically address shared factors of multi-ple malnutrition forms, often termed as double-or triple-duty interventions, across various societal subsystems to ensure maximum and sustainable impact. 5The typically viewed benchmark in evaluation research is randomized controlled trials, however, they face ethical and practical challenges.Moreover, they may not effectively address the dynamic and adaptive nature of population-level interventions rooted in a systems approach.Using long-term, government-led and/or funded national surveillance programmes offers a more appropriate and sustainable method for evaluating populationlevel systemic interventions. 6,7Therefore, understanding the scope and characteristics of nutrition-related surveillance programmes is an important initial step to assess countries' capability to monitor and evaluate systemic interventions.This understanding can also help guide the development and improvement and capacity building actions.

Methods
Our systematic scoping review is based on the six-stage published framework. 123][14] This protocol has been registered with the Open Science Framework. 15

Search strategy
We searched for relevant studies, reports and documents on currently ongoing nutrition surveillance programmes.We searched two online databases, PubMed® and Scopus, for relevant publications using a combination of key search terms: monitor*, survey*, surveillance, weight, nutrition*, diet*, food*, eating and health*.We searched the databases from January 2014 to 29 January 2022 for most countries, and for some countries from inception to 29 January 2022, and updated this search to 26 June 2023.More details are available in the online repository. 16or our manual search, we conducted both forward and backward reference searches of the identified articles in the database search to locate additional relevant publications. 12To ensure that all relevant information is extracted, we searched for methodological documents of surveillance programmes on government and programme websites and from institutional websites of international organizations, such as WHO.
We complemented our desk-based literature search with consultation meetings and email communications with senior nutrition officials at health ministries in study countries from February until September 2022.These officials have been responsible for the design, deployment or implementation of national nutrition (health) surveillance programmes, and/or are familiar with existing or the development of nutrition surveillance programmes in their countries. 17The officials were purposively invited through our own networks with Asian governments.
We continuously refined and expanded our literature search and evaluation criteria in response to earlier search and consultation results, where deskbased research (academic database and manual search) and expert consultation informed each other iteratively. 12

Eligibility criteria
Here we define a nutrition surveillance, or monitoring, programme as repeated collection, analysis, interpretation and dissemination of primary data on the anthropometric and biochemical nutrition outcomes (exclusively or embedded) and behavioural or food system indicators that influence anthropometric or biochemical nutrition outcomes. 18,19uch programmes are an important part of a wider nutrition information system. 7To achieve a broader understanding of national government-led nutrition-related surveillance, we included programmes operated by nonhealth sectors within the food system.These programmes must either feature nutrition outcome indicators or collect data intended to enhance nutrition.In this review, primary data refer to data that are collected first-hand for a specific programme or purpose. 7e covered ongoing nutrition surveillance programmes in 18 low-and middle-income countries, 11 WHO South-East Asia Region Member States and seven WHO Western Pacific Region Member States.Ten of these 18 countries are ASEAN Member States (Table 1).We included ASEAN Member States due to their sustained health and nutrition partnerships, which allow for local and regional research objectives to be collectively developed and achieved for maximum impact.We excluded the ASEAN Member State Singapore because it is classified as a high-income country.To provide a more comprehensive picture of the nutrition surveillance in south-east Asia, we also included other Member States of the WHO South-East Asia and Western Pacific Regions.This inclusion allows for wider comparisons of similarities and differences across countries that share contextual characteristics, and further promotes international learning and sharing of experiences.
Our selection of programmes and relevant publications was defined by the eligibility criteria as specified under the inclusion and exclusion criteria presented in Box 1.

Study selection
We imported the results from the academic database search into Endnote X9 (Clarivate, London, England).Two researchers independently screened titles and abstracts using the specified eligibility criteria in the open-access web-based systematic reviewing application Rayyan (Rayyan, Cambridge, United States of America).We resolved disagreements following abstract screening through discussions to build consensus.To ensure a low number of false negatives, we screened a preliminary test set of 50-100 records. 12Three reviewers independently screened the full text of eligible publications.A fourth reviewer addressed discrepancies between the three reviewers at the full-text screening stage.

Data extraction
We extracted data for each surveillance programme via a purposively developed form on the basis of components and operation characteristics that are listed in the updated United States Centers for Disease Control and Prevention (CDC) guidelines for public health surveillance programmes.The 2001 CDC updated guidelines are commonly applied, and intended to be universally applicable for describing and evaluating a large variety of different public health surveillance programmes. 122he data extraction form included the authors, publication date, publication title, type of primary surveillance, main objectives (which we categorized based on previous work) 123,124 and the country where the programme is being implemented.We further disaggregated the extracted information according to: (i) collected data and used method;

Data synthesis
To provide a comprehensive description of surveillance at a national and programme level (Box 2), we analysed six adapted attributes derived from the 2001 CDC updated guidelines, 122 which are informed by a set of standards for evaluation (detailed description available in online repository). 16,126We also enquired with national health and nutrition officials to obtain missing information and verify our description.We did not identify any conflicting informa-tion between the different identified documents.We triangulated findings from the programme analysis, and consultations with officials to present the current state of nutrition (-related)

Results
,123,160,161 We also received information about 11 programmes and five related publications 79,97,98,121,162 directly from national health and nutrition officials (Fig. 1).Most identified programmes had a methodological report which was publicly available on the respective government or international agency website.Several reports were not available in English, 67,68,148,162 in which case, the programme details were provided or verified by national nutrition and health officials, or complemented with peer-reviewed articles.
We provided an overview of the descriptive analysis of the included programmes and a summary of the main findings in Box 3.More detailed and programme-level information is available in the online repository. 16

Identified programmes
We identified 82 nationally representative government-led and -funded surveillance programmes that repeatedly collect primary data on nutrition and/or diet outcome indicators.Some of the programmes implemented a first round within the last decade and may conduct, or have planned, future rounds.The programmes were either local or internationally linked.On a national level, health ministries (or an embedded research institute) coordinated and implemented most programmes that collect nutrition and nutrition-related indicators.The ministries use the collected data to inform the development and evaluation of national policies and nutrition programmes.To a lesser extent, programmes are designed to collect data that governments can leverage for informed decision-making and to monitor national objectives.
0,162 In nine countries, large-scale periodic national nutrition surveys were implemented (Bhutan, Brunei Darussalam, China, Democratic People's Republic of Korea, India, Sri Lanka, Timor-Leste, Thailand and Viet Nam). 28,33,50,54,58,99,111,116,120,135,156ational micronutrient status surveys were used in three countries (Bangladesh, Nepal and Viet Nam); 26,87,157,163 and in Myanmar, Sri Lanka and Viet Nam, national nutrition and micronutrient surveys were implemented. 83,103,163Further details on the key characteristics and indicators are available in the online repository. 16he type of collected data, used methods and monitoring frequency differed substantially across programmes and countries.We found that all countries periodically collect weight and height data, and most countries take waist and hip circumferences (Table 1).China, Indonesia, Lao People's Democratic Republic, Philippines and Viet Nam continuously collect weight and height data among children younger than 5 years. 38,65,92,119,121We only identified one programme in China and three in India that measure skinfold thickness. 40,57,58ll countries periodically measure anaemia with varying monitoring frequency (ranging from a single round to 12-year intervals).Nine countries (Bangladesh, China, India, Indonesia, Myanmar, Nepal, Philippines, Sri Lanka and Thailand) also collect data

Inclusion criteria
• We included a programme when it is ongoing, led and funded by a country's governmental body and repeatedly collects, analyses, interprets and disseminates primary data on anthropometric, biochemical, behavioural and/or food system indicators relating to nutrition.
Examples include large-scale, repeated surveys, and data from repeatedly used sentinel sites and educational/childcare settings.Primary data refers to data that are collected for surveillance purposes. 7• Related publications were included when these covered methodological information on one, or multiple ongoing nationally representative nutrition (and health) surveillance data collection programme(s).• We included nutrition (-related) surveillance programmes that are ongoing, or with minimally one recently completed data collection round, that are conducted on a continuous and/ or periodic basis.• We included programmes that had implemented at least one data collection round, and are predicted to see future rounds.• Programmes and related publications that we included had to collect primary data on anthropometric and/or nutrition-related indicators, and be operating in at least one of the Member States of WHO South-East Asia Region, the Association of Southeast Asian Nations and/or China.The programme could cover any age and demographic group.• We included all types of literature (or study designs) that provide information relevant to the design, methods, findings, and impact on or information for, at least one surveillance programme, such as government reports and conference papers.• Publications could be written in any language.

Exclusion criteria
• Organizational or researcher-led collections and analyses of nutrition and related data which do not form part of a larger surveillance programme were not included.• Publications that focus on secondary use of data from nutrition surveillance programmes when official documentation on methodological and operational information is available.• Nutrition and health surveillance programmes that were discontinued before 2022.
• Programmes and related publications that do not collect primary data on anthropometric and/or nutrition indicators.on most other micronutrient deficiencies (Table 2; available at https:// www .who.int/publications/ journals/ bulletin/ ).The Thai government implemented a surveillance programme that annually collects information on median urinary iodine among pregnant women, in households and antenatal care clinics. 162Most countries periodically collect biochemical and anthropometric data on diet-related noncommunicable diseases, mainly with the WHO STEPwise approach to noncommunicable disease risk factor surveillance. 164ietary intake monitoring also varied substantially across countries (Table 3 and Table 4).Periodic collection of individual food intake data occurred in all countries, of which 17 out of 18 countries are using food frequency questionnaires in varying lengths and with a focus on different aspects.These questionnaires mainly focus on specific behaviours linked to diet-related noncommunicable diseases.Most countries (Bangladesh, Brunei Darussalam, Cambodia, China, Democratic People's Republic of Korea, India, Lao People's Democratic

Data quality
We reported on programme-level validated measures and quality assurance methods that were used to ensure data quality.We also report data completeness as an indicator of data quality.

Flexibility
We based our analysis of flexibility on whether the programme reports any evidence of accommodated changes to the programme methods and operation between data collection rounds with the purpose of incorporating relevant indicators and adapting to population's nutritional needs. 125

Representativeness
We analysed national and programme-level representativeness through identification of geographical locations, subpopulation groups, and accurate reporting of nutrition-related events.The latter refers to the notion whether the collected data can be disaggregated by sociodemographic variables important to nutrition. 126

Timeliness and simplicity
The timeliness and simplicity of surveillance programmes refers to both national and individual programme structure, and ease of operation.Based on available information, we analysed whether the identified programme digitized their data collection, processing and dissemination during its most recent round.We also describe whether there are any overlapping years of indicator selection, any reported barriers to timely and simple implementation, and the central body and partnerships being responsible for surveillance programmes at country level.

Stability
We analysed stability by considering any mentioned issues during the collection, management and provision of data, and the consistency of data collection (were there any gaps between data collection?), and type of funding.
a Our selection was guided by the adapted US Centers of Disease Control and Prevention guidelines 122 on public health surveillance system evaluation.Republic, Malaysia, Nepal, Philippines, Sri Lanka, Thailand, Timor-Leste and Viet Nam) also use a 24-hour dietary recall method in one, or multiple, of their programmes to measure individual intake. 33,36,38,50,58,59,78,87,89,92,111,116,135,142,156hina uses weighed food records to measure quantitative information on individual diets. 38All countries except Brunei Darussalam periodically collect information on infant and young child feeding practices, with an interval between 1 to 10 years.In Bangladesh, Sri Lanka and Thailand, iodine content is measured in salt production as part of their national nutrition survey.Generally there is limited nutrition-related food environment and food system monitoring within the identified surveillance programmes.Moreover, we did not identify any government-led programmes run by non-health departments that included food environment and/or wider food system indicators, or monitored data across the food system with the purpose of controlling malnutrition.

Data quality
To ensure high quality of the collected data, all countries use rigorous supervision, personnel training and applying the most recently available global standards at the time of programme implementation.A total of 49 national and internationally linked programmes report higher than 80% response rates (range: 53-99).2]105 National or local country surveillance programmes showed evidence of flexibility as they expanded indicators and/or subpopulation groups between their latest data collection rounds.

Representativeness
Coverage of population groups for nutrition-outcome indicators differs to a large extent.Except Brunei Darussalam, all countries cover anthropometric information on nutrition status among children younger than 5 years, and all countries include women of reproductive age for anthropometry at varying time intervals.
Bangladesh, China, India, Indonesia, Malaysia, Philippines and Thailand have national surveillance that covers measurement of anthropometric nutrition status among all age groups (Table 1).Common missing groups across most countries' surveillance were elderly people for anthropometry, and school-aged children and elderly people for dietary assessment.
All countries collect nutrition and diet outcome data that can be disaggregated by key sociodemographic factors, including socioeconomic status.Six countries rely on the Global School-Based Student Health Surveys for young adolescent (10-14 years of age) weight and height (self-reported) which cannot be disaggregated by socioeconomic status.Aside from one programme in Bangladesh and two in India, urban deprived areas or informal settlements, and mobile populations (including homeless, internally displaced people, refugees, nomadic populations) are generally not represented within national nutrition surveillance.

Type of data collected
• Seventeen countries have implemented national programmes that exclusively collect data on individual nutrition and diet-outcome indicators.• No countries monitor indicators on all forms of malnutrition, or on food environment and wider food systems.

State of nutrition surveillance
• The majority of countries have digitized data collection, implemented comprehensive measures to promote data quality, and scaled-up or increased monitoring scope in comparison to its preceding round.• Most programmes report higher than 80% response rates.
• All countries, if information is available, implement rigorous training and supervision practices prior to and during data collection.• All countries have one or more programmes that adopted programmatic changes between data collection rounds.

Stability
Included programmes in most countries did not report to have experienced any preparation or operation issues in their latest round.Reported issues mainly related to financial costs (two programmes), logistical challenges (two programmes), and few trained data collection personnel (one programme).Most countries' continuous and periodic programmes collected data with consistent time intervals between rounds and with limited interruptions.104,121,151,156 Other countries' national nutrition surveillance mainly includes programmes that were reliant on external support.

Discussion
Through our analysis of publicly available literature and consultations with national nutrition and health officials, we identified and described ongoing national and internationally linked nutrition surveillance programmes for 18 countries.Our review shows large variations between countries in terms of scope, and frequency of monitoring.Many countries implement one or multiple nutrition-and diet-focused periodical surveillance programmes with wide intervals.Few countries collect continuous comprehensive information on individual diet and micronutrient biomarkers.The latter finding is consistent with a recent review on the availability and use of micronutrient data in low-and middle-income countries worldwide. 166While individual dietary data and biochemical measures of micronutrient status are highly accurate, continuous collection of such data is time-and cost-intensive. 167More recent innovative dietary assessments -for example, the diet quality questionnaire by the Global Diet Quality Projecthave been developed and trialled in some south-east Asian countries, which can help reduce cost and participant burden. 168ile the identified nutrition surveillance programmes generally allow for disaggregation of important nutrition-related sociodemographic variables, most surveys do not accurately represent populations in vulnerable settings with prevalent malnutrition issues.Many low-and middle-income countries have a substantial proportion of their population living in such settings, 169 164 that differ per programme and country, often specific foods associated with increased noncommunicable disease risk. Food frequency questionnaire in the World Health Organization STEPwise approach to noncommunicable disease risk factor surveillance.164 d Only covers adolescents 15-19 years of age. e Mitored by multiple programmes.f 24-hour recall questionnaire.g Individual food insecurity question(s) on lack of food over a specific period of time.h Individual micronutrient intake through supplementation and/or specific micronutrient-dense foods.i Three questions on commercially packed ready to drink beverages.fosters a more sustainable nutrition surveillance.170 Not unique to south-east Asia, most other countries implement internationally linked multicountry survey platforms, for example, Demographic and Health Surveys, Multiple Indicator Cluster Surveys and the WHO STEPwise approach.171 Such large-scale programmes can be valuable for enhancing national governments' capacity to map national trends and collect standardized, internationally comparable, highquality nutrition data.However, the intervals of these surveys are 4-5 years, which prevents timely monitoring and evaluation.Furthermore, the surveys generally require external technical and financial support and can be timeintensive to implement.7 We found limited monitoring of food environment and broader food system indicators within nutrition surveillance programmes led by national health authorities.Similarly, non-health governmental bodies also inadequately monitor these indicators to directly back the national nutrition agenda.Ideally, countries' local health and/or nutrition agencies should possess the expertise and capacity to transform broader environment data into comprehensible nutritionsensitive indicators and metrics.This information should then be used to devise, monitor and enhance nutrition interventions and policies.172 Integration of data from nutrition surveillance programmes with other sectoral data can also be valuable as it reduces labour, time and economic costs.125 There is substantial data monitoring within south-east Asia on food environments and systems through agricultural and/or industry surveys; commercial databases; academic studies; and routine national surveillance data (food supply and prices).79 Such data, in combination with other data sources, are presently transformed by international initiatives and research groups into interpretable nutritionsensitive indicators such as nutritious food affordability.79,168 By incorporating three different literature search strategies, including an academic database search, grey literature search, and consultations with senior officials of national health authorities where possible, we ensured that we produce a comprehensive review. In dition, including 14 national health and nutrition officials knowledgeable about the surveillance programmes in their respective countries as co-authors further reinforces the credibility of our review findings.Another strength of the study is the use of CDC's integrative and adaptive framework to obtain a more comprehensive picture of the current state of nutrition surveillance in south-east Asia.
Our review also has limitations.We mainly focused on nationally representative, government-led and encuestas internacionales.La cobertura de las diferentes subpoblaciones y la frecuencia del seguimiento varían sustancialmente de un país a otro.Se halló una integración limitada de los indicadores del entorno alimentario y del sistema alimentario en general en estos programas y ningún programa supervisa específicamente los datos que tienen en cuenta la nutrición en todo el sistema alimentario.También es limitada la vigilancia relacionada con la nutrición de las personas que viven en áreas urbanas desfavorecidas.La mayoría de los programas de vigilancia están digitalizados, utilizan medidas para garantizar la alta calidad de los datos y presentan evidencias de flexibilidad; sin embargo, muchos se aplican de forma incoherente y dependen del apoyo financiero de organismos externos.Conclusión Se deben fomentar y apoyar los esfuerzos para mejorar la eficiencia temporal, el alcance y la estabilidad de la vigilancia nacional de la nutrición, así como la integración con otros datos sectoriales, para permitir un seguimiento y una evaluación sistémicos de las intervenciones contra la malnutrición en estos países.Once NA Viet Nam 116,117,120,163 Once d NA Once

Physical measurement, by country Interval between rounds, years Birth a Children < 5 years Children 5-9 years Adolescents 10-19 years Women of reproductive age Pregnant women Lactating women Adult men Elderly people
surveillance in south-east Asia and China.
• All countries have one or more programmes that included new indicators and subpopulation groups.• Seven countries monitor anthropometry indicators among all age groups.• Nine countries collect data on most micronutrient biomarkers.• Five countries monitor individual dietary intake periodically among all age groups.• While there are variations in terms of representativeness across countries, elderly people were commonly not represented in the monitoring of anthropometry and dietary data.• Limited surveillance in urban deprived areas.• All countries collect data which can be disaggregated by important nutrition-related population characteristics.• Most programmes that collect nutrition and nutrition-related indicators were coordinated and implemented by countries' health ministries.• Most countries' local surveillance programmes collected data on nutrition-outcome and/ or diet-outcome indicators with consistent time intervals between rounds.• Nine countries have an internally funded national surveillance programme that exclusively collects nutrition-outcome data.

Table 3 . Individual dietary assessment in study countries Measurement, by country Interval between rounds, years, by target group Children < 5 years Children 5-9 years Adolescents 10-19 years Women of reproductive age Pregnant women Lactating women Adult men Elderly people
(continues. ..)Bull World Health Organ 2023;101:690-706F| doi: http://dx.doi.org/10.2471/BLT.23.289973Nutrition surveillance programmes in south-east Asia and western Pacific Remco Peters et al.

by country Interval between rounds, years, by target group Children < 5 years Children 5-9 years Adolescents 10-19 years Women of reproductive age Pregnant women Lactating women Adult men Elderly people
NA: Not applicable.a Includes short versions adapted to different survey platforms (World Health Organization STEPwise approach)

Table 4 . Household-level dietary assessments in study countries Country Interval between rounds of assessment, years
Food records assessment of individuals living in households with children who are younger than 5 years.e Household one-day food weighing as part of 24-hour recall.f Household food security (experienced a food shortage during the last year).Bull World Health Organ 2023;101:690-706F| doi: http://dx.doi.org/10.2471/BLT.23.289973Nutrition surveillance programmes in south-east Asia and western Pacific Remco Peters et al.Bull World Health Organ 2023;101:690-706F| doi: http://dx.doi.org/10.2471/BLT.23.289973Nutrition surveillance programmes in south-east Asia and western Pacific Remco Peters et al.
a Monitored by multiple programmes.b Household use and purchase of fortified food.c Household food-related coping strategies.d

Resumen Programas nacionales de vigilancia de la nutrición en 18 países de las regiones de Asia Sudoriental y el Pacífico Occidental: una revisión sistemática de alcance Objetivo Identificar
y analizar los programas de vigilancia en curso relacionados con la nutrición que dirigen o financian las autoridades nacionales de los países de las regiones de Asia Sudoriental y el Pacífico Occidental.Métodos Se realizaron búsquedas sistemáticas de publicaciones en PubMed® y Scopus, búsquedas manuales en la literatura gris y consultas con funcionarios nacionales de salud y nutrición, sin restricciones de tipo de publicación ni de idioma.Se incluyeron países de ingresos bajos y medios de la Región de Asia Sudoriental de la Organización Mundial de la Salud y de la Asociación de Naciones de Asia Sudoriental y China.Para analizar los programas incluidos se adaptó el marco de evaluación de la vigilancia de la salud pública de los Centros para el Control y la Prevención de Enfermedades de Estados Unidos.Resultados Se identificaron 82 programas de vigilancia en 18 países que recopilan, analizan y difunden repetidamente datos sobre nutrición o indicadores relacionados.Diecisiete países aplicaron una encuesta periódica nacional que recopila exclusivamente indicadores de resultados nutricionales, por lo general junto con programas de